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The “point” of the matter! A pencil can be dangerous

Sharpened Pencil

Recently, I had this ten-year-old boy, who came to me with a four-day-old injury. Apparently, the boys were playing rather boisterously at school. As is usual children, especially if they have not been cautioned earlier, quite forget that even everyday objects can be quite dangerous. While horsing around, one of the children drove the nicely sharpened point of his pencil into the child’s arm.

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Second Opinion – How to go about it?

The days are long gone when we accepted what came out of our doctor’s mouth as the gospel truth. And good riddance too! There are many reasons why the majority of the population is eager to seek a second opinion. And a third, and a ….

Why do patients seek a second opinion?

  • Easy Availability: At least in urban and semi-urban areas thanks to the significantly increased number of doctors, there is easy availability of doctors in all hues and specialties. There is no shortage of super-specialists too in most major metropolitan areas. Referral to specialists and super-specialists is not tightly regulated as in the Western countries, and it is possible to meet most consultants at very short notice and in the majority of cases as walk-in patients.
  • Greater Awareness & Desire to seek better care in the general population: Everybody wants the best possible treatment for themselves and their loved ones. What has changed from the past is that the current population is much more aware – both in terms of knowledge about the disease and about knowing one’s rights than previous generations. And that is a good thing! This has automatically led to an improvement in standards of health care in our country. It has forced institutions and doctors to upgrade and improve their skills. It is altogether another aspect that the pendulum has swung too far and like anything in excess, has been carried too far and completely spoiled the patient-doctor relationship.
  • Unsatisfactory or Adverse outcome or course in an illness: It is but natural to seek another doctor’s opinion when things are not going according to plan, or if it seems to the patient, that their treating doctor is not in control of the management.

Preventing the Need for Second Opinion

My favorite mantra to all patients.

  • Research your doctor: If you have the time and are given the opportunity, research your doctor thoroughly, before going to one either on the recommendation of another patient, a doctor, or the first convenient doctor that you picked from the internet.
  • Don’t do detailed research on your disease: There is a plethora of information available on the internet. It is impossible to distinguish the good stuff from the bad stuff. There is a lot of good stuff there, mind you, but there is a greater amount of misinformation. Even well-known sites have sections that contain junk that is just the fantasy/figment of imagination/opinion of the author.
    If you must research go UpToDate and look in the patient section. The official CDC site is also very useful. These are just two of the incredibly good sites. But, the vast majority are filled with very iffy information. In any case, it is impossible for you to acquire as much information as your doctor. Even for your doctor, it is not easy to remain abreast with the development in one’s own field. To think that as a layperson, you will get the authentic information is asking for the moon.
  • Learn to trust the doctor that you choose: Unless and until you feel that you chose the wrong doctor, let your chosen professional do his/her job. Medicine has always been an inexact science, unlike arithmetic. In many cases, there are different ways to skin a cat. If you have chosen your doctor well, s/he will ask for a second opinion even before it crosses your mind. A conscientious medical professional freely takes a second opinion when it is in the best interest of the patient. There is no ego involved. With experience, you realize that if one is hung up on ego, you get hung!

You want a second opinion – how do you go about it?

By far the best way is to request your treating doctor to take a second opinion for you. As I have already mentioned, a really good and self-confident doctor does not in any way balk at asking for second opinions.
In a large hospital, there are many consultants of the same specialty. Ask around, especially the paramedical staff. They are the ones who have seen the results of all the doctors that visit and are usually able to suggest the best person available. Beware of two things though! Sometimes the paramedical staff get awed by the personalities involved and may not be able to give you an objective opinion. Secondly, it can be a very touchy situation if you zero in on a consultant of the same hospital, and the two consultants don’t get along.
Better to ask your family practitioner/family member/friend suggest somebody who is outside the hospital. Even if it is from the same hospital, you can always tell your treating consultant that my so and so has recommended this doctor. Since things are not going too well, can we take a second opinion? Do hasten to add that you know that your doctor is doing his/her best.

Final words of advice

  • Please see the right specialist!
    This sounds elementary, but the stimulus for this post was a recent incident. A infant had been referred to me for constipation, and I was suspecting a rare congenital cause for the constipation, and had advised a few investigations. The parents must have had some doubts so they went back, and decided to consult a pediatrician! Apparently, the treatment suggested by the pediatrician did not work, so after 15 days, they came back to me. I pointed out to them that they were certainly entitled to a second opinion, but if they wanted one, they should have consulted another pediatric surgeon.
    Having a one doctor fit all illnesses is a very common problem in India. It is a legacy of the days when family doctors were ubiquitous, supreme and trusted. Now that the urban population prefers to go to specialists, they find a trusted specialist. It does not matter what is that person’s specialty. All problems are brought to that person’s door. It is not a problem provided that person has the humility to refer to the appropriate specialist but all too often human vanity kicks in.
  • Beware! If you ask for a second opinion more often than not, you get a different opinion!
    Most of the times, as I have alluded to above, Medicine is an Art and there are many ways to get the job done. I know quite a few doctors find it very difficult to say that I agree with the previous doctor and the recommended treatment. I have seen many prescriptions of second opinions where the prescribed drugs are the same – it is just the brand names that have been changed!
    If you get a different opinion, you may now be confused. Time for a third opinion? It can go on, you know!
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Mucoceles – Swelling On Inner Side Of The Lip

Mucocele of the lower lip

Mucoceles are relatively commonly seen in children.

How do they form?

The minor salivary glands, and, there are over 600 of them, are small glands that produce saliva. The glands are too small to be seen by the naked eye and consist of a small globular gland. The saliva that forms in the gland drains out through a narrow tube (the duct) into the mouth. This saliva helps us chew our food and also starts the process of digesting food.

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Faculty at CEMAST, Mumbai courses

Bronchoscopy workshop CEMAST
Bronchoscopy workshop CEMAST May 7, 2016 7 chest surgeons from different parts of India took part

CEMAST (Center of Excellence for Minimal Access Surgery Training), Mumbai conducts courses for surgeons all year around in various disciplines.

 

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Pillion riding for Adults Only

Dangerous Pillion riding

Pillion riding is dangerous even for adults but is an absolute no-no for children. It is also illegal to transport children riding pillion on two-wheelers. People who regularly travel by two-wheelers cite the convenience.  Given the traffic situation in most towns and cities in India, there is more than a grain of truth in that. Public transport is not as good as it should be. Moreover, public transportation at odd hours or during emergencies may just not be available. Two-wheelers are also much cheaper to maintain than cars.

Yet, children should never travel on two-wheelers, as it is downright dangerous. Most people, do not pay any heed to safety and don’t realize how dangerous it is to ferry children around on two-wheelers. We have this gentleman, nicely protected by his helmet (I suspect more out of fear of the law than by concerns about safety!), ferrying not one, but two kids in the rear.

There is no protection and no restraint. Any accident (whosoever is at fault, whether it be the rider himself, other drivers, the road or pedestrians), will result in the children being flung with great force out of the vehicle and crashing into anything that is nearby. Please do yourself and your children (whom you profess to love so much!) a favor and only travel with them, properly restrained in car seats in the back of four-wheelers! Please!

I have seen children actually dozing off at the back, when pillion riding. I quickly move away from such riders as I would certainly not want to be the instrument of their doom!

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Care of the uncircumcised penis in the child

First the don’t! – Do not pull back the foreskin forcibly under any circumstances.

At birth, the foreskin, sometimes called the prepuce, is attached to the end of the penis, an area known as the glans. Over time, the foreskin separates from the glans, forming a space between the skin and the glans. Separation is completed in 50 percent of boys by age 3 years, 95 percent by age 5 years, and 99 percent by adolescence. So just wait it out, and it is very likely that the skin will retract back up to the junction between the head and the body of the penis, on its own.
In fact, there is a risk of injury to either the foreskin or the glans, if the foreskin is retracted forcibly. Many of these children who have had injury need to be circumcised at a later date.

Now for the actual care:

  • Change diapers frequently – This is not the place to save money. Don’t wait to get what you consider a “full load”! Apart from possible infections of the skin of penis in boys, you can get vaginitis in girls, or diaper rashes or increased risk of urinary tract infections.
  • Always clean poop from front to back – that way you are unlikely to get poop on to the genitals.
  • Treat it like just any other body part – clean the genitals with water and a mild soap (no role for using anti-bacterial soaps in routine bathing, as it only encourages the emergence of bacteria that are resistant to multiple drugs).
  • When the foreskin becomes retractable: Later, when the foreskin is fully retractable, boys should be taught the importance of washing beneath the foreskin on a regular basis. The foreskin should be dried before pulling it forward. The pulling it back to its normal position is very important, as if left behind, it becomes swollen and painful, a condition called as paraphimosis – if this should ever happen, please seek urgent, immediate attention.
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Doctor, my child’s testis cannot be felt! Should we do an ultrasound examination?

Is an ultrasound necessary in a child who has an undescended testis?

Almost every patient that comes to me for consultation for undescended testis, comes armed with an ultrasound (USG) report, that the parent will promptly proceed to show me after the initial formalities, even before I have had a chance to ask as to why they are consulting me.
The sad part is that ultrasound is not only unnecessary but actually misleading in children with undescended testes [1].

USG is accurate in predicting examination findings in only 54% of children. Additionally it delays required surgery in infants by as many as 3 months.
The algorithm for managing undescended testis only requires whether an experienced pediatric surgeon can palpate the testis or not. So please do not get unnecessary tests done.
1. Ultrasound Overused to Diagnose Undescended Testicle